Open Dialogue -- Alternative Care for Psychosis In Finland Developed By Jaakko Seikkula

By Will Hall

Over the past two decades, Dr. Jaakko Seikkula’s hospital team in Finland has advanced and refined “Open Dialogue,” a family and social network approach to first episode psychosis care, and this way of working has garnered widespread attention for dramatically improving outcomes. Open Dialogue de-emphasizes US-style pharmaceutical intervention and instead establishes a dialogue with the patient, provides immediate help, and organizes “a treatment meeting” within twenty-four hours of the initial contact. The results consistently show that this way of working reduces hospitalization, lowers use of medication, and leads to less recurrance of crisis when compared with psychosis treatment as usual. For example, in a five-year follow-up (Seikkula et al. 2006), 83% of patients have returned to their jobs or studies or were job seeking, thus not receiving government disability. In the same study, 77% did not have residual psychotic symptoms. Open Dialogue is gaining growing support in the US after Robert Whitaker, in his book Anatomy of An Epidemic, featured Open Dialogue as an effective alternative to the poor treatment outcomes associated with overuse of medications.

I met Dr. Seikkula’s at the INTAR conference in New York and was deeply impressed by him and his work. The Open Dialogue method assumes meaning in ‘psychosis’ and welcomes the person having these experiences to participate equally in the treatment planning process. Mary Olson, Sekkula’s US colleague, told me that Open Dialogue sees psychosis as “happening between people, not within a person.” That succinct statement in and of itself has the power to reinvent mental health care, putting attention on helping improve the social relationships surrounding the person in crisis as the key to recovery.

In an Open Dialogue session video I watched, a treatment meeting discussion with clinicians, family, client and therapist resulted in a change in attitude in the therapist, which was a key to improving the client’s situation. This strikes me as revolutionary in outlook – the problem is in the network of relationships surrounding a person who is “in crisis,” rather than assuming the problem is inside the person’s head. Helping the social network – including changing attitudes of providers – may be the way forward, not just focusing on achieving change in the person in crisis. The problem lies between people and in the broader social context, not in a pathology in the individual.

Open Dialog has achieved dramatic treatment outcomes — avoiding hospitalization, lowering use of meds, and getting people through crisis. I encourage the peer recovery movement to promote Open Dialogue as a promising new model of care.

In discussions about Open Dialogue, some have been concerned about inclusion of family members in the dialogue process. I think that caution is warranted as there may be abuse in the family; practitioners have to be very sensitive to power and trauma issues. When I raised this with Olson and Seikkula, they were clear that clients are not compelled to include family members if they are against it, and safety and abuse issues are given priority. It’s also worth remembering that separation from an abusive family is not always the best strategy, because by removing oneself you may lose the opportunity to confront and challenge the abuse. At a “first break” there is an opportunity to bring family dynamics out into the open and achieve power shifts in relationships. Someone who engages with an abusive family member directly, and successfully overcomes emotional dependency or fear, might then have stronger resources to transform deeper problems. When you separate from your family, you might carry unresolved feelings and patterns that shape the rest of your relationships and life, and find you haven’t really separated at all.

Below are some excerpts about Open Dialogue, and check out the linked files.

— Will Hall

The Open Dialogue patients were hospitalized less frequently, and three per cent of these patients required neuroleptic drugs, in contrast to 100 per cent of the patients in the comparison group. At the two-year follow-up, 82 per cent had no, or only mild non-visible psychotic symptoms compared to 50 per cent in the comparison group. Patients in the Western Lapland site had better employment status, with 23 per cent living on disability allowance compared to 57 per cent in the comparison group. Relapses occurred in 24 per cent of the Open Dialogue cases compared to 71 per cent in the comparison group (Seikkula et al., 2003). A possible reason for these relatively good prognosis was the shortening of the duration of untreated psychosis (DUP) to 3.6 months in Western Lapland, where the network-centred system has emphasized immediate attention to acute disturbances before they become hardened into chronic conditions.

The aim of the treatment meeting explicitly became defined as that of dialogue, in which the patient can find voice, thus reducing the person’s sense of isolation. This approach emphasizes the process of finding language for psychotic experience that previously was inexpressible and creating a shared understanding of the crisis within a network. The use of ordinary words and creation of joint meanings tends to generate a collaborative set of relationships and to open up an avenue to people’s own knowledge, skills, and capabilities…. One of the effects of these language practices in the treatment meeting is to create a transparency in psychiatric care—indeed, the “openness” of Open Dialogue. The deleterious effects of contradictory injunctions originating from different contexts can be countered by making the confusing messages open for discussion during the meeting. There are no separate staff meetings to talk about the “case,” so all “case management” issues, including medication, hospitalization, and psychotherapeutic options, must be addressed in the meeting with everyone in the network present….

What we avoid: Diagnostic procedures; Medication; Control; The language of pathology; Search for an ‘inner core’; Discussions about the patient in her or his absence; Becoming expert competent;

Becoming sub-specialist; Individual perspective; Thinking that problems are to be solved; Questionnaires.